December 31, 2006

ACR Radiology Coding Source™ Nov-Dec 2006 Q and A

Radiologist Assistant and Radiology Practitioner Assistants Questions and Answers

The following questions and answers address the responsibilities and training required of radiologist assistants (RAs) and radiology practitioner assistants (RPAs), and the impact of the Supervision Rule on their (RAs and RPAs) roles. If you have additional questions, contact the Government Relations and Economics and Health Policy department: (800)227-5463, ext 4132.

Q: What are the roles of radiologist assistants, radiology practitioner assistants, and physician assistants?

A: Radiologist assistants (RAs) and radiology practitioner assistants (RPAs) are registered radiological technologists who have undertaken a higher level of education and training. RAs and RPAs are required to be supervised by a radiologist. Some radiology practices have hired physician assistants (PAs) and are training them to practice radiology.

Differences between radiologist assistants (RAs) and radiology practitioner assistants (RPAs) have emerged from differences in educational standards, impacting the level of practice and overall autonomy of RAs and RPAs in clinical practice. The RPA acronym, however, has caused some confusion, since it sometimes has been incorrectly associated with the benefits and requirements of the physician assistant (PA) designation.

Physician assistants (PA) differ from RAs in that PAs are qualified to receive a national physician identification number (NPI) that allows them to bill separately for their services. PAs are trained in general medicine, while RAs' training focuses on radiology. Nonetheless, PAs also are supervised by a physician, within the state-established limits. PAs may not function in a supervisory capacity; however, they may perform diagnostic tests under their own statutory benefits and state requirements for physician supervision. (Medicare Transmittal 1725).

Q: Are RAs trained to perform studies that require personal supervision?

A: Yes, RAs receive education through an advanced academic program (baccalaureate or post-baccalaureate program) encompassing a nationally recognized radiologist assistant curriculum and a radiologist directed clinical preceptorship. There are a number of procedures in the RA curriculum deemed to be appropriate for an RA to perform under direct supervision, but currently defined by CMS as requiring personal supervision. Medicare's Supervision Rule currently does not allow RAs to perform studies that require personal supervision unless the supervising radiologist is in the room.

Q: Does the Supervision Rule apply to both the hospital and nonhospital (office and independent diagnostic testing facility) settings?

A: No, the Supervision Rule does not pertain to the hospital setting (inpatient or outpatient), since Medicare reimburses for the technical component of hospital services directly to hospitals.

In the hospital setting, radiology procedure performance is governed by the Conditions of Participation, which specify that procedures should be performed based on:

  1. Pertinent state law
  2. JCAHO guidelines
  3. Hospital rules and regulations

However, although the Supervision Rule does not apply in the hospital setting, Medicare's payment policy (Medicare Claims Processing Manual, Chapter 13, 80.1) specifies that if the physician is not present for the supervision portion of an S&I code, which requires personal supervision, a 52 modifier (reduced services) must be appended to the procedure code to reflect that only interpretation is provided.

In the office and independent diagnostic testing facility (IDTF) settings, the Supervision Rule applies to the performance of diagnostic radiology procedures. Medicare will reimburse studies performed in the nonhospital setting under the Medicare physician fee schedule, when the requirements of the Supervision Rule are met.

Q: How does the Supervision Rule apply to RAs?

A: Medicare's Supervision Rule applies to the technical component of the diagnostic tests performed in office or freestanding settings. There are three levels of physician supervision required for diagnostic tests as outlined in Transmittal B-01-28:

General supervision: The procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the procedure. Under general supervision, the physician is responsible for training nonphysician personnel, such as an RA, who performs diagnostic procedures and for maintaining necessary equipment and supplies.

Direct supervision: The physician must be present in the office suite and immediately available to assist and direct throughout the procedure. This does not mean that the physician must be present in the room when the procedure is performed.

Personal supervision: A physician must be in the room during the procedure.

Refer to the CMS Web site for a copy of the 2007 Medicare Physician Fee Schedule, which lists the current procedures and assigned supervision levels.

Q: Does the Incident-To Rule Apply to RAs?

A: The incident-to rule does not apply to diagnostic tests. The incident-to rule covers non-hospital services when incidentally provided by supervised non-physicians as part of a medical service provided by the physician. The rule requires that there be an established physician relationship with the patient before a nonphysician can provide services collectively with a physician; therefore, most diagnostic and therapeutic procedures performed by radiologists are excluded. However, certain procedure-oriented radiology specialists (interventionalists, radiation oncologists, and breast imaging specialists) may be able to utilize this rule in certain instances when billing for procedures performed by an RA outside the hospital setting.

Q: Do only the radiological supervision and interpretation codes (RS&I) require personal supervision?

A: No, more than just the radiological supervision and interpretation codes require personal supervision, as noted in Medicare regulations. However, many codes requiring personal supervision are designated as RS&I codes. As mentioned above, go to the CMS Web site for a listing of the appropriate supervision levels currently assigned by Medicare for 2007.

Q: Does the use of teleradiology meet the above participation requirements for a "personal" level of physician supervision?

A: No, teleradiology does not meet the requirements for "personal" supervision since, by definition, this level of supervision requires the physician to be in the room.

Q: Are there any other laws or pertinent regulations?

A: Yes, any radiology practice located in the following states should carefully examine state statutes and regulations that control RAs' scope of practice: Arkansas; Florida; Iowa; Mississippi; Montana; New Mexico; New York; Oregon; Tennessee and Wyoming.

Because the states regulate, through licensing, the practice scope, supervision requirements, and medical liability of nonphysician practitioners, the ACR advises that radiology practices consult with qualified local counsel for guidance on their state’s legislation and regulations.

Please look for a future JACR article for more detail and an update on the role of RAs.


ACR Bulletin, NOV, 2001, "Clarification Given by CMS on Ordering Diagnostic Tests Rule, Supervision Rule and ICD-9 Coding Guidelines."

ACR Bulletin, June, 2001, "New Supervision Regulations Effective July 1, 2001"

CMS Transmittal 1725, July 16, 2001.

CMS Web site Listing of 2007 Supervision Levels in the Medicare Physician Fee Schedule at RVU07A2 - Updated 12/04/06 [ZIP 3MB]

Program Memorandum Carriers (CMS Transmittal B-01-28)

The Medicare Carrier Manual, Section 15022(E)(1)

Q: Is anything being done to change the ability to use RAs to perform procedures requiring personal supervision?

A: Yes, the ACR and American Society of Radiologic Technologists (ASRT) are working with CMS to update the level of supervision required. The ACR has met with CMS several times to clarify this issue. Until a change can be effected at the national level, radiology practices must not bill Medicare services when RAs perform studies that are not at the required level of supervision. That is, if personal supervision is required, it is illegal to submit the claim to Medicare if the study was performed by the RA under direct supervision from the radiologist.

Q: Can an RA interpret studies?

A: No, RAs are not trained, credentialed or licensed to interpret radiology studies, and the American College of Radiology, American Society of Radiologic Technologists, and American Registry of Radiology Technologists do not endorse interpretation by RAs as part of their role. Only physicians should give interpretations.

Q: Does the Supervision Rule apply to the technical component or to the professional component?

A: The Supervision Rule applies to the technical component of the imaging codes in the non-hospital (office or IDTF) settings. The Supervision Rule is a national policy set forth by the Centers for Medicare and Medicaid Services (CMS) and, thus, not at the discretion of the local carrier medical directors.